Skip to content
How It Works
Explore
Resources Ask a Question
Who It's For
Patients Caregivers Providers
Log In Ask a Question
PubMed This is a summary of 14 peer-reviewed journal articles Updated
Pediatrics · Cleft Lip and Palate

The Marathon of Care: Hearing, Speech, and Dental Monitoring

At a Glance

Children born with a cleft lip or palate require long-term specialized care beyond initial surgeries. Because the palate muscles connect to the ears and mouth, patients need ongoing monitoring for middle ear fluid, speech difficulties like velopharyngeal insufficiency (VPI), and dental alignment.

Cleft care is often described as a “marathon” because the physical repair of the lip and palate is only the beginning. Because the anatomy of the mouth is interconnected with the ears and teeth, your child will need specialized monitoring for years to come [1].

Hearing: The Ear-Palate Connection

Almost every child born with a cleft palate will experience fluid buildup in the middle ear [2]. This happens because of a mechanical connection:

  • The Muscle Issue: The tensor veli palatini is a muscle in the palate that normally opens the Eustachian tube (the tube that drains the ear) every time you swallow [3]. In a cleft palate, this muscle is often shorter or not attached correctly, so the tube remains closed [4].
  • Fluid and Infection: When the tube doesn’t open, fluid gets trapped behind the eardrum. This “muffled” hearing is like listening to the world underwater, which can delay speech development [2].
  • Pressure Equalization (PE) Tubes: Doctors often place small ventilating tubes in the eardrum to drain the fluid [5]. Because the ear issues are chronic, children with clefts may need several sets of tubes throughout childhood [6].

Speech: Managing the “Nasal” Voice

As your child starts to talk, the goal is for the soft palate to close against the back of the throat to block air from going into the nose.

  • Velopharyngeal Insufficiency (VPI): This occurs when the palate is too short or doesn’t move well enough to create a tight seal [7].
  • Hypernasality: If the seal isn’t tight, air leaks through the nose during sounds like “p,” “b,” and “t,” creating a “nasal” sounding voice [8].
  • Compensatory Habits (Glottal Stops): When a child can’t build up pressure in their mouth to make sounds like “p” or “k,” they may develop “glottal stops.” This sounds like a hard grunt, a cough, or a sudden “catch” deep in the throat [9]. Regular evaluations by a speech-language pathologist (SLP) are vital to catch and un-learn these patterns early [10].

Dental: Navigating a Unique Smile

The cleft often passes through the “alveolar ridge” (the gum line where teeth grow), which creates specific dental challenges:

  • Missing or Extra Teeth: It is very common for the tooth right at the cleft to be missing (hypodontia) [11]. Conversely, some children have “extra” teeth (supernumerary teeth) in that area [12].
  • Class III Malocclusion: Because surgical scarring can sometimes slow the growth of the upper jaw, the lower teeth may eventually sit in front of the upper teeth (an “underbite”) [13].
  • Long-Term Care: Your child will likely need a pediatric dentist and an orthodontist to manage these issues from the first baby tooth through the final alignment of adult teeth [14].

Common questions in this guide

Why do children with cleft palates need ear tubes?
Children with cleft palates often have a muscle imbalance that keeps the Eustachian tube closed. This traps fluid behind the eardrum, leading to muffled hearing. Doctors place tiny ventilating tubes in the eardrum to drain this fluid and protect speech development.
What is velopharyngeal insufficiency (VPI)?
VPI happens when the soft palate is too short or doesn't move properly to create a tight seal against the back of the throat. This causes air to leak through the nose during speech, resulting in a nasal-sounding voice and difficulty making certain sounds.
Will my child with a cleft lip or palate have missing teeth?
It is very common for children to have dental issues near the cleft area, including missing teeth or sometimes extra teeth. An orthodontist and pediatric dentist will carefully monitor their dental growth to manage these issues.
How can I tell if my child is developing compensatory speech habits?
If your child cannot build enough air pressure in their mouth to make sounds like 'p' or 'k', they might start making glottal stops. This can sound like a hard grunt, a cough, or a sudden catch deep in the throat.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How often should my child have a hearing test, and do you recommend 'preventative' ear tubes during their first palate surgery?
  2. 2.Can you explain the specific speech assessments our child will have as they grow? How do you distinguish between VPI and a child just learning to speak?
  3. 3.When is the right time to start orthodontic treatment, and how will missing or extra teeth in the cleft area be managed?
  4. 4.Is my child at high risk for a Class III malocclusion, and what signs should we watch for as their face grows?
  5. 5.What can we do at home to support speech development while we wait for surgical milestones?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (14)
  1. 1

    Centralization of cleft care in the UK. Part 6: a tale of two studies.

    Ness AR, Wills AK, Waylen A, et al.

    Orthodontics & craniofacial research 2015; (18 Suppl 2()):56-62 doi:10.1111/ocr.12111.

    PMID: 26567856
  2. 2

    The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems.

    Heidsieck DS, Smarius BJ, Oomen KP, Breugem CC

    Clinical oral investigations 2016; (20(7)):1389-401 doi:10.1007/s00784-016-1828-x.

    PMID: 27153847
  3. 3

    The role of tensor veli palatini muscle (TVP) and levetor veli palatini [corrected] muscle (LVP) in the opening and closing of pharyngeal orifice of Eustachian tube.

    Gyanwali B, Li H, Xie L, et al.

    Acta oto-laryngologica 2016; (136(3)):249-55 doi:10.3109/00016489.2015.1107192.

    PMID: 26624574
  4. 4

    Differences in the Tensor Veli Palatini Between Adults With and Without Cleft Palate Using High-Resolution 3-Dimensional Magnetic Resonance Imaging.

    George TN, Kotlarek KJ, Kuehn DP, et al.

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2018; (55(5)):697-705 doi:10.1177/1055665617752802.

    PMID: 29360409
  5. 5

    Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review.

    Vanneste P, Page C

    Journal of otology 2019; (14(2)):33-39 doi:10.1016/j.joto.2019.01.005.

    PMID: 31223299
  6. 6

    Long-Term Otitis Media Outcomes in Infants With Early Tympanostomy Tubes.

    Luu K, Park J, Shaffer AD, Chi DH

    Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2020; (163(6)):1258-1263 doi:10.1177/0194599820931414.

    PMID: 32539603
  7. 7

    What's New in Cleft Palate and Velopharyngeal Dysfunction Management?

    Naran S, Ford M, Losee JE

    Plastic and reconstructive surgery 2017; (139(6)):1343e-1355e doi:10.1097/PRS.0000000000003335.

    PMID: 28538580
  8. 8

    Hollow Complete Denture With a Speech Bulb Prosthesis: A Case Report.

    Sarmalkar SD, Aras M, Nagarsekar A, Rajagopal P

    Cureus 2024; (16(3)):e55671 doi:10.7759/cureus.55671.

    PMID: 38586630
  9. 9

    Laryngeal Aerodynamics, Acoustics, and Hypernasality in Children With Cleft Palate.

    Fujiki RB, Munday J, Johnson R, Thibeault SL

    Journal of speech, language, and hearing research : JSLHR 2025; (68(4)):1676-1690 doi:10.1044/2024_JSLHR-24-00763.

    PMID: 40020658
  10. 10

    Validation of an objective assessment tool for velopharyngeal insufficiency in cleft lip and palate children.

    Fersing C, Thevarajah D, Sanquer E, et al.

    Journal of stomatology, oral and maxillofacial surgery 2024; (125(12 Suppl 2)):101968 doi:10.1016/j.jormas.2024.101968.

    PMID: 39002728
  11. 11

    Cleft sidedness and congenitally missing teeth in patients with cleft lip and palate patients.

    Jamilian A, Lucchese A, Darnahal A, et al.

    Progress in orthodontics 2016; (17()):14 doi:10.1186/s40510-016-0127-z.

    PMID: 27135068
  12. 12

    Prevalence of Dental Anomalies in Primary vs. Permanent Dentition in Individuals with Non-Syndromic Cleft Lip and Palate: A Systematic Review and Meta-Analysis.

    Srivastav S, Hermann NV, Tewari N, et al.

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2025; 10556656251398076 doi:10.1177/10556656251398076.

    PMID: 41342785
  13. 13

    Transverse differences between cleft lip and palate and non-cleft palate with skeletal Class III malocclusion using buccolingual inclination: a cone-beam computed tomography retrospective study.

    He J, Jiang L, Song S, Mo S

    BMC oral health 2022; (22(1)):631 doi:10.1186/s12903-022-02675-4.

    PMID: 36550501
  14. 14

    Permanent Tooth Agenesis and Maxillary Hypoplasia in Patients with Unilateral Cleft Lip and Palate.

    Antonarakis GS, Fisher DM

    Plastic and reconstructive surgery 2015; (136(5)):648e-656e doi:10.1097/PRS.0000000000001694.

    PMID: 26505722

This page provides educational information on long-term hearing, speech, and dental care for children with cleft lip and palate. Always consult your child's cleft team and pediatric specialists for personalized medical advice.

Get notified when new evidence is published on Cleft lip/palate.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.